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JUDITH T.TERRY �� ?� Town Hall, 53095 Main Road
TOWN CLERK ` y _ P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ;
MARRIAGE OFFICER y4 p�A. �1�' Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER : 1 �goo Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER �
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3472-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner GORDON, EVELYN S.
Mailing Address 1 P. O. BOX 158
Mailing Address 2
City St Zip PECONIC NY 11958-0158
Property Address 1 400 DIAMOND LANE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-2604
Tax Map No. section 68.00 block 1 lot 2.000
Cross Street SOUNDVIEW AVENUE
Issue Date: 5/17/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OIr,FI-CE"OF THE TOWN CLERK " .SFRA-
Town of Southold 4j = Application No. 31
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road -< 7 $10.00 - Residential
P. O. Box 1179 cry ;'
$25.00 - Non-Residential
Southold, New York 11971
Telephone �j , 1k
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ id,
" DATE P)707,
OWNER NAME: %7i1)
OWNER MAILING ADDRESS: 27.7 //9S"e--0/sT
OWNER PROPERTY ADDRESS: 7D6 aD
OWNER TELEPHONE NUMBER: "/6- ,74,3"--..24,e
we(���'4 A- i -4 lege? r—
TAX MAP NO. : Section`. & ? Block / Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing V
Residential / Non-Residential
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signa re/'of. pplicant
RECEIVED BY: "
Town'-Clerk's Office
DATE: "